Therapeutic Instructions Research Articles

The contribution of therapeutic instruction to covert sensitization

R ecent controlled studies demonstrate that aversion therapies can be effective treatments for certain behaviour disorders such as alcoholism (Ashem and Donner, 1968) and sexual deviation (Feldman and MacCulloch, 1971). However, the mechanism of action in the various forms of aversion therapy has not been determined. As one form of aversion therapy, covert sensitization employs descriptions of noxious scenes as aversive stimuli. An earlier study (Barlow, Leitenberg and Agras, 1969) suggested that pairing descriptions of noxious scenes with scenes of the undesired behavior was the critical procedure in covert sensitization. There, a single case design was used with two sexual deviates. Sexually arousing scenes were paired with descriptions of nausea and vomiting during the first phase, while in a second phase the same sexually arousing scenes were presented alone, and finally, pairing was reinstated. Put another way, these phases represent acquisition, extinction and re-acquisition respectively. During the pairing of scenes in the first phase, deviant arousal declined, rose again when the pairing of scenes was removed, and dropped in the final phase when pairing was reinstated. This appeared to demonstrate the effectiveness of pairing in the procedure. It is possible, however, that therapeutic instructions and the resulting expectancy of improvement present in both covert sensitization phases, were responsible for the effectiveness of the treatment, since the patient may have viewed the middle extinction phase as non- therapeutic. To test this notion, the procedure of the first experiment was changed somewhat. Four homosexual Ss were told that the acquisition procedure (covert sensitization) with pairing would temporarily worsen their sexual deviation and that the extinction procedure (no pairing) was therapeutic. The experiment began with the no pairing procedure with therapeutic instructions to create the desired expectancies at the outset and to test for an initial placebo effect. In addition, an objective measure of sexual arousal, penile circumference change, was recorded. If pairing is the necessary and sufficient procedure in covert sensitization, then deviant sexual arousal should decrease during covert sensitization despite instructions to the contrary and, conversely, no improvement should occur during the no pairing, placebo phase.

The contribution of therapeutic instructions to systematic desensitization

An experiment was conducted in which different pretreatment instructions were presented to snake phobic Ss undergoing desensitization. The Ss were either presented with therapeutic instructions, no explicit instructions or misleading instructions. It was hypothesized that the greater the awareness-inducing properties of the instruction, the greater would be its facilitative effect on desensitization. Hence, it was predicted that the reduction in snake phobic behaviour would be greatest for the desensitization and therapeutic instruction condition, less for the desensitization and no-instruction condition and still less for the desensitization and misleading instruction condition. All three conditions led to a reduction in snake phobic behaviour. Contrary to prediction, no significant differences were noted between desensitization Ss receiving therapeutic instructions and those receiving no explicit instructions. As predicted, both these groups displayed a greater reduction in snake phobic behaviour than the misinformed Ss. The presentation of therapeutic information to misinformed Ss after they had completed desensitization had no apparent effect on altering their snake phobic behaviour, suggesting that “awareness” must be present during treatment. A high proportion of non-instructed Ss became aware of the therapeutic nature of the research. Aware Ss in all desensitization conditions experienced a greater reduction in snake phobic behaviour than unaware Ss.

Effects of expectancy on the outcome of systematic desensitization and implosive treatments for analogue anxiety

Fifty college female subjects, selected on the basis of their pretest, avoidance of a snake, were randomly assigned to four conditions; (a) desensitization, (b) implosion, (c) avoidance response, and (d) no-therapy. Half of the subjects received therapeutic instructions to establish a positive expectancy of improvement while, the other half received instructions designed to avoid establishing expectancy of improvement. After four sessions, the posttest was administered. It was found that desensitization and implosion both resulted in decreased pulse rate. The expectancy manipulation strongly affected overt, behavioral measures of fear. Implosion was most influenced by the expectancy effects, while positive expectancy implosion showed the most improvement over the traditional no-therapy group.

Systematic desensitization with pre-treatment and intra-treatment therapeutic instructions

Three groups of 10 Ss each received tape-recorded desentitization along a snake approach hierarchy. One group (SD++) received therapeutic instructions before each desensitization session. A second group (SD+) was presented with therapeutic instructions before only the initial desensitization session. The third group (SD) received no therapeutic instructions. As compared with 10 untreated and 10 “pseudodesensitized” Ss, the Ss in the SD++ and SD+ conditions displayed significant behavioral improvements, while those in the SD group did not. Improvements for Ss in the SD++, SD+ and SD conditions did not differ.

Systematic desensitization in an experimental setting: A follow-up study

A follow-up study was done of female college student volunteers who had been treated for marked fear of snakes using systematic desensitization under four experimental conditions. In the original study four groups were differentiated on the basis of: (1) therapeutic instructions and praise; (2) therapeutic instructions alone; (3) praise alone; and (4) neither therapeutic instructions nor praise. At follow-up Ss were reassessed on a behavioral test of their ability to approach and handle a snake, and were interviewed to determine whether they had discerned the conditions of the original experiment. Twenty-five of the original thirty-two Ss (78 per cent) were assessed a mean of 9.5 months after their experimental post-test. All four groups maintained their original gains and the inter-relationships of the groups remained stable: only instructions had a statistically significant added effect over systematic desensitization; the reinforcement and interaction factors did not attain statistical significance. From the interview data it could not be demonstrated that Ss were aware of either the instructional or reinforcement conditions of their respective groups.

Systematic desensitization, therapeutically oriented instructions and selective positive reinforcement

The relative contributions of therapeutically oriented instructions and selective positive verbal reinforcement to systematic desensitization therapy were investigated. Thirty-two female college students with marked fear of snakes were divided into four treatment groups. All Ss were given systematic desensitization therapy. In addition, Group 1 was given therapeutic instructions and praise; Group 2 was given instructions but no praise; Group 3 was given no therapeutic instructions but was given praise; and Group 4 was given neither instructions nor praise. All four groups improved significantly in their ability to approach the snake; however, an analysis of variance for a factorial design indicated that only instructions had a significant effect; the reinforcement and interaction factors were not significant.

Contribution of selective positive reinforcement and therapeutic instructions to systematic desensitization therapy.

Contribution of selective positive reinforcement and therapeutic instructions to systematic desensitization therapy.

USE OF ANTICOAGULANTS: PRO AND CON.

The panelists devote a large part of this discussion to answering direct questions relating to the use of anticoagulants. Among the problems considered are the advisability of anticoagulant therapy in acute myocardial infarction and after the acute episode, steps to be taken when a major operation or dental extraction is necessary, variations in response among different patients and at different times in the same patient, the duration of use of anticoagulants, the range of prothrombin time or level that constitutes the “therapeutic range,” and instructions for the patient in the event of hemorrhage at a time when medical help is not immediately available.